title: Late-onset triple A syndrome: a risk of overlooked or delayed diagnosis and management.
abstract: OBJECTIVE
  A 33-year-old man was referred for the first time to the Division of Neurology because of the presence and progression of neurological symptoms. Dysphagia, weakness, reduced tear production, and nasal speech were present. In order to point the attention of late-onset triple A syndrome we describe this case and review the literature.
  
  
  METHODS
  Hormonal and biochemical evaluation, Schirmer test, tilt test and genetic testing for AAAS gene mutations.
  
  
  RESULTS
  Late-onset triple A syndrome caused by a novel homozygous missense mutation in the AAAS gene (A167V in exon 6) was diagnosed at least 17 years after symptom onset.
  
  
  CONCLUSIONS
  The association between typical signs and symptoms of triple A syndrome should suggest the diagnosis even if they manifest in adulthood. The diagnosis should be confirmed by Schirmer test, endocrine testing (both basal and dynamic), genetic analysis, and detailed gastroenterological and neurological evaluations. Awareness of the possible late onset of the disease and of diagnosis in adulthood is still poor among clinicians, the acquaintance with the disease is more common among pediatricians. The importance of an adequate multidisciplinary clinical approach, dynamic testing for early diagnosis of adrenal insufficiency and periodical reassessment of adrenal function are emphasized.
authors.affiliation: Istituto Nazionale Neurologico Carlo Besta, IRCCS, Milan, Italy.
authors.forename: Andrea
authors.initials: A
authors.lastname: Salmaggi
authors.forename: Lucia
authors.initials: L
authors.lastname: Zirilli
authors.forename: Chiara
authors.initials: C
authors.lastname: Pantaleoni
authors.forename: Gabriella
authors.initials: G
authors.lastname: De Joanna
authors.forename: Francesca
authors.initials: F
authors.lastname: Del Sorbo
authors.forename: Katrin
authors.initials: K
authors.lastname: Koehler
authors.forename: Manuela
authors.initials: M
authors.lastname: Krumbholz
authors.forename: Angela
authors.initials: A
authors.lastname: Huebner
authors.forename: Vincenzo
authors.initials: V
authors.lastname: Rochira
mesh_terms: D000309:Adrenal Insufficiency / Q000175:diagnosis / Q000235:genetics*; D000328:Adult; D017668:Age of Onset; D015352:Dry Eye Syndromes / Q000175:diagnosis / Q000235:genetics*; D004931:Esophageal Achalasia / Q000235:genetics*; D006801:Humans; D008297:Male; D020125:Mutation, Missense; D009419:Nerve Tissue Proteins / Q000235:genetics*; D028861:Nuclear Pore Complex Proteins / Q000235:genetics*; D013577:Syndrome
chemical_list: C416506:AAAS protein, human; D009419:Nerve Tissue Proteins; D028861:Nuclear Pore Complex Proteins